Female genital mutilation

Female genital mutilation

Road sign near Kapchorwa, Uganda, where FGM is outlawed but still practised by the Pokot, Sabiny and Tepeth people.
Description	Partial or complete removal of the external female genitalia, or other injury to the female genital organs, for non-medical reasons
Areas practised	28 countries in West Africa, Eastern Africa, North Africa and sub-Sarahan Africa; parts of Asia and the Middle East
Number affected	140 million worldwide as of 2013, including 101 million in Africa
Age performed	Typically ages 4–10; in some communities a few days after birth

Female genital mutilation (FGM), also known as female genital cutting and female circumcision, is defined by the World Health Organization (WHO) as "all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons." FGM is practised as a cultural ritual in 28 countries in western, eastern, north-eastern and sub-Saharan Africa, in parts of Asia and the Middle East, and within immigrant communities elsewhere. It is usually carried out on girls aged four to ten, typically without anaesthesia, by a traditional circumciser using a knife, razor or scissors. Wealthier families may have it performed in a hospital.

The WHO has divided the procedures into four categories. Type I is the removal of the clitoris (clitoridectomy) and clitoral hood, and Type II (excision) the removal of the clitoris and inner labia. Type III (infibulation) is the removal of all or part of the inner and outer labia and the fusion of the wound; a small hole is left for the passage of urine and menstrual blood, and the wound is opened up for intercourse and childbirth. Type IV refers to procedures such as symbolic piercing of the clitoris, and cutting into the vagina to widen it (gishiri cutting). Health effects can include recurrent infections, chronic pain, infertility, epidermoid cysts, complications during childbirth and fatal hemorrhaging.

Around 140 million women and girls are living with the effects of FGM, including 101 million in Africa; 85 percent undergo Types I and II, while Type III is predominant in Djibouti, Somalia and Sudan, and in parts of Eritrea, Ethiopia and Mali. The practice is rooted in gender inequality, ideas about purity, modesty, aesthetics, honour and cultural identity, and attempts to control women's sexuality by reducing their sexual desire. In communities that practise it, it is supported by both women and men. According to Sudanese surgeon Nahid Toubia, who has campaigned against FGM for decades, it is harder to persuade the women to give it up than the men, because they see it as a source of status and authority.

The United Nations General Assembly voted unanimously in 2012 to ban the practice. There is significant opposition to the practice in Africa itself, but Sylvia Tamale, a Ugandan legal scholar, cautions that some African feminists object to what she calls the imperialist infantilization of African women inherent in some of the Western criticism.

Terminology

A young girl raises the flag in South Sudan, where FGM is known as tahur, meaning purification.

The procedures were known as female circumcision (FC) until the early 1980s. The term female genital mutilation came into use after the publication of The Hosken Report: Genital and Sexual Mutilation of Females (1979) by the American feminist writer Fran Hosken (1920–2006). UNICEF and the WHO write that the word mutilation differentiates FGM from male circumcision and stresses its severity. The Inter-African Committee on Traditional Practices Affecting the Health of Women and Children began using female genital mutilation in 1990, and the following year the WHO recommended the term to the United Nations. It has since become the dominant term within the international community and in medical literature.

Other terms in use include female genital cutting (FGC), female genital surgeries, female genital alteration, female genital excision, and ethnic female genital modification. State-sponsored groups tend to call it FGM, while private groups use FGC. UNFPA and USAID use the combined term female genital mutilation/cutting (FGM/C).

Local terms include tahara in Egypt, tahur in Sudan and bolokoli in Mali, words meaning cleanliness or purification. Several countries refer to Type I as sunna circumcision, although the term sunna wrongly implies that it is required by Islam. Type III (infibulation) is known as pharaonic circumcision in Sudan – a reference to the practice in Ancient Egypt under the Pharaohs – but as Sudanese circumcision in Egypt. The term infibulation stems from the Roman practice of fastening a fibula or brooch across the outer labia of female slaves.

History

Origins

But if a man wants to know how to live, he should recite it [a magical spell] every day, after his flesh has been rubbed with the b3d [an unknown substance] of an uncircumcised girl and the flakes of skin [šnft] of an uncircumcised bald man.

Inscription on Egyptian sarcophagus, 2000–1700 BCE

Political scientist Gerry Mackie writes that the origins of FGM are obscure. There is a reference to it on a sarcophagus in the Egyptian Museum dating back to Egypt's Middle Kingdom, c. 2000–1700 BCE (see right). The Greek geographer Strabo (c. 64 BCE – c. 23 CE) wrote of it after visiting Egypt around 25 BCE: "This is one of the customs most zealously pursued by them [the Egyptians]: to raise every child that is born and to circumcise the males and excise the females." The philosopher Philo of Alexandria (c. 20 BCE–50 CE) contrasted the Egyptian practice with God's commandment in the Book of Genesis (c. 950–500 BCE) that boys be circumcised, writing: "the Egyptians by the custom of their country circumcise the marriageable youth and maid in the fourteenth (year) of their age, when the male begins to get seed, and the female to have a menstrual flow."

A heiroglyph of a woman in labour and the physical examination of mummies by Australian pathologist Grafton Elliot Smith (1871–1937) suggest that Type III was not performed in ancient Egypt, although as part of the mummification process, the skin of the outer labia was pulled toward the anus to form a covering over the pudendal cleft (possibly to prevent sexual violation), which gave the appearance of Type III. Smith wrote that soft tissues were often removed by embalmers, or had simply deteriorated, so that it was not possible to determine from the mummies whether Types I and II had been practised.

Egyptologist Mary Knight writes that there is only one extant reference from antiquity that suggests FGM might have been practised outside Egypt. Xanthus of Lydia wrote in a history of Lydia in the fifth century BCE: "The Lydians arrived at such a state of delicacy that they were even the first to 'castrate' their women." Knight argues from the context that "castrate" refers here to a form of sterilization.

Mackie writes that FGM in Africa became tied up with the slave trade. The Egyptians took captives in the south to be used as slaves, and slaves from Sudan were exported through the Red Sea to the Persian Gulf. The English explorer William Browne (1768–1813) reported in 1799 that infibulation was carried out on slaves in Egypt to prevent pregnancy, and the Portuguese missionary João dos Santos (d. 1622) wrote of a group in Mogadishu who had a "custome to sew up their Females, especially their slaves being young to make them unable for conception, which makes these slaves sell dearer, both for their chastitie, and for better confidence which their Masters put in them." Thus, Mackie argues, patterns of slavery across Africa account for the patterns of FGM found there, and "[a] practice associated with shameful female slavery came to stand for honor."

Europe and the United States

Isaac Baker Brown "set to work to remove the clitoris whenever he had the opportunity of doing so."

Gynaecologists in 19th-century Europe and the United States would also remove the clitoris for various reasons, including to treat masturbation, believing that the latter caused physical and mental disorders. The first reported clitoridectomy in the West was carried out in 1822 by Karl Ferdinand von Graefe (1787–1840), a surgeon in Berlin, on a teenage girl regarded as an "imbecile" who was masturbating.

Isaac Baker Brown (1812–1873), an eminent English gynaecologist, president of the Medical Society of London, and co-founder of St. Mary's Hospital in London, believed that the "unnatural irritation" of the clitoris caused epilepsy, hysteria and mania, and "set to work to remove [it] whenever he had the opportunity of doing so," according to his obituary in the Medical Times and Gazette. He did this several times between 1859 and 1866, sometimes with removal of the inner labia too. Doctors in London were outraged when he published his views in a book, On the Curability of Certain Forms of Insanity, Epilepsy, Catalepsy, and Hysteria in Females (1866), accusing him of quackery, mutilation and operating without consent. He died in poverty after being expelled from the Obstetrical Society the following year.

In the United States J. Marion Sims (1813–1883), regarded as the father of gynaecology – controversially so because of his experimental surgery on slaves – followed Brown's work, amputating a woman's clitoris in 1862, "for the relief of the nervous or hysterical condition as recommended by Baker Brown," after she complained of period pain, convulsions and bladder problems. Sources differ as to when the last clitoridectomy was performed in the United States. A 1985 paper in the Obstetrical & Gynecological Survey said that American obstetricians were performing them into the 1960s to treat hysteria, erotomania and lesbianism.

Classification, health aspects

Circumcisers, age of girls

Anatomy of the vulva, showing the clitoral glans, clitoral crura, corpora cavernosa, and vestibular bulbs.

The procedure is generally performed without anaesthesia by a traditional circumciser, usually an older woman who also acts as a midwife, known as a gedda in Somalia or daya in Egypt and Sudan. It may also be performed by the local male barber. Non-sterile cutting devices are used, such as knives, razors, scissors, cut glass and sharpened rocks, and sutures may be made from agave or acacia thorns. Wealthier families may pay instead for the services of a nurse, midwife or doctor using a local anaesthetic.

The procedures are typically carried out between the ages of four and ten, though they may also be conducted on infants, or postponed until before marriage or after the birth of the first child. Comfort Momoh, a midwife who specializes in treating FGM, writes that in Ethiopia the Falashas perform it when the child is a few days old, the Amhara on the eighth day after birth, and the Adere and Oromo between four years and puberty. It may be carried out on one girl alone, or on a group of girls at the same time.

Types I and II

FGM Types I–III

The WHO divides FGM into four categories (see image right for Types I–III). Type Ia is the removal of the clitoral hood, which is rarely, if ever, performed alone. More common is Type Ib (clitoridectomy), the partial or total removal of the clitoris. According to the WHO, "the clitoris is held between the thumb and index finger, pulled out and amputated with one stroke of a sharp object. Bleeding is usually stopped by packing the wound with gauzes or other substances and applying a pressure bandage. Modern trained practitioners may insert one or two stitches around the clitoral artery to stop the bleeding."

Type II (excision) is partial or total removal of the clitoris and inner labia, with or without removal of the outer labia. Around 85 percent of women who experience FGM undergo Types I and II. The WHO classification has been criticized because it relies on reports from the women themselves using local terms; a 2006 study published in the British Medical Journal suggested that the reliability of these reports is low.

Type III

Type III (infibulation) is the removal of all external genitalia and the fusing of the wound, leaving a hole the size of a matchstick head for the passage of urine and menstrual blood. The inner and outer labia are cut away, with or without excision of the clitoris. After the procedure the girl's legs are tied together from hip to ankle for 2–6 weeks to allow the wound to heal. The immobility causes the labial tissue to bond, forming a wall of flesh and skin across the vulva. A small hole is created by inserting something into the wound before it closes, such as a thorn, a twig or rock salt. Around 15 percent of women who experience FGM undergo Type III; most FGM procedures (80–90 percent) in Somalia, Sudan and Dijbouti are Type III. Momoh describes such a procedure:

[E]lderly women, relatives and friends secure the girl in the lithotomy position. A deep incision is made rapidly on either side from the root of the clitoris to the fourchette, and a single cut of the razor excises the clitoris and both the labia majora and labia minora.

Bleeding is profuse, but is usually controlled by the application of various poultices, the threading of the edges of the skin with thorns, or clasping them between the edges of a split cane. A piece of twig is inserted between the edges of the skin to ensure a patent foramen for urinary and menstrual flow. The lower limbs are then bound together for 2–6 weeks to promote haemostatis and encourage union of the two sides ...

Healing takes place by primary intention, and, as a result, the introitus is obliterated by a drum of skin extending across the orifice except for a small hole. Circumstances at the time may vary; the girl may struggle ferociously, in which case the incisions may become uncontrolled and haphazard. The girl may be pinned down so firmly that bones may fracture.

The vulva is cut open for sexual intercourse and childbirth. It can take up to two years for a husband to penetrate his wife's infibulated vagina. Anthropologist Janice Boddy wrote in 1989 that it is a point of pride for men in Sudan that their wives give birth within a year of marriage, so the local midwife may be sent for secretly to enlarge the wife's opening. Hanny Lightfoot-Klein, a social psychologist, interviewed 300 Sudanese women and 100 Sudanese men in the 1980s, and described the penetration by the men of their wives' infibulation:

The penetration of the bride's infibulation takes anywhere from 3 or 4 days to several months. Some men are unable to penetrate their wives at all (in my study over 15%), and the task is often accomplished by a midwife under conditions of great secrecy, since this reflects negatively on the man's potency. Some who are unable to penetrate their wives manage to get them pregnant in spite of the infibulation, and the woman's vaginal passage is then cut open to allow birth to take place. ... Those men who do manage to penetrate their wives do so often, or perhaps always, with the help of the "little knife." This creates a tear which they gradually rip more and more until the opening is sufficient to admit the penis. In some women, the scar tissue is so hardened and overgrown with keloidal formations that it can only be cut with very strong surgical scissors, as is reported by doctors who relate cases where they broke scalpels in the attempt.

Type IV

A variety of other procedures are collectively known as Type IV, which the WHO defines as "all other harmful procedures to the female genitalia for non-medical purposes, for example, pricking, piercing, incising, scraping and cauterization." The WHO does not include cosmetic procedures such as labiaplasty, or procedures used in sex reassignment surgery, within any of its categories of FGM (see below).

Type IV ranges from ritual nicking of the clitoris to stretching the labia or clitoris, burning or scarring the genitals, or introducing harmful substances into the vagina to tighten it. Political scientist Stanlie M. James writes that Mairo Usman Mandara, a Nigerian surgeon, has described several practices that involve cutting internal genitalia (introcision). These include hymenotomy, the removal of a hymen regarded as too thick; James writes that this is practised by the Hausa in West Africa. They also include gishiri cutting, where the vagina's anterior wall is cut with a razor blade or penknife to enlarge it; according to James, this might be done during obstructed labour or to address other medical issues. Izett and Toubia write that it often results in vesicovaginal fistulae and damage to the anal sphincter.

Reinfibulation and defibulation

Women may request reinfibulation – the restoration of the infibulation – after giving birth, known in Sudan as El-Adel (re-circumcision or, literally, "putting right" or "improving"). Two cuts are made around the vagina, then sutures are put in place to tighten it to the size of a pinhole. Vanja Bergrren writes that this has the effect of mimicking virginity. It may also be carried out just before marriage, after divorce, or even in elderly women to prepare them for death.

Defibulation, or deinfibulation, is a surgical technique to reverse the closure of the vaginal opening after a Type III infibulation, and consists of a vertical cut opening up normal access to the vagina. This may be accompanied by removal of scar tissue and labial repair. Procedures have been developed to repair clitoral integrity, such as by Pierre Foldes, a French urologist and surgeon, and Marci Bowers, an American surgeon who studied his work, using intact clitoral tissue from inside women's bodies to form a new clitoris.

Complications

Knives used for FGM in East Africa, photographed in 2004

FGM has no known health benefits. It has both immediate and late complications, which depend on several factors: the type of FGM; the conditions in which the procedure took place and whether the practitioner had medical training; whether unsterilized or surgical single-use instruments were used; whether surgical thread was used instead of agave or acacia thorns; the availability of antibiotics; how small a hole was left for the passage of urine and menstrual blood; and whether the procedure was performed more than once (for example, to close an opening regarded as too wide, or re-open one too small).

Immediate complications include fatal hemorrhage, acute urinary retention, urinary infection, wound infection, septicemia, tetanus, and transmission of hepatitis or HIV if instruments are unsterile or reused. It is not known how many girls and women die from the procedure; Alexia Lewnes writes that few records are kept, complications may not be recognized, and fatalities are rarely reported.

Late complications vary depending on the type of FGM performed. The formation of scars and keloids can lead to strictures, obstruction, or fistula formation of the urinary and genital tracts. Urinary tract sequelae include damage to urethra and bladder with infections and incontinence. Genital tract sequelae include vaginal and pelvic infections, dysmenorrhea, dyspareunia and infertility. Complete obstruction of the vagina results in hematocolpos and hematometra. Other complications include epidermoid cysts that may become infected, neuroma formation, typically involving nerves that supplied the clitoris, and pelvic pain.

FGM may complicate pregnancy and place women at higher risk for obstetrical problems, which are more common with the more extensive FGM procedures. Thus, in women with Type III FGM who have developed vesicovaginal or rectovaginal fistulae – holes that allow urine and faeces to seep into the vagina – it is difficult to obtain clear urine samples as part of prenatal care, making the diagnosis of conditions such as preeclampsia harder. Cervical evaluation during labour may be impeded, and labour prolonged. Third-degree laceration, anal sphincter damage, and emergency caesarean section are more common in women who have experienced FGM. Neonatal mortality is also increased. The WHO estimated that an additional 10–20 babies die per 1,000 deliveries as a result of FGM; the estimate was based on a 2006 study conducted on 28,393 women attending delivery wards at 28 obstetric centers in Burkina Faso, Ghana, Kenya, Nigeria, Senegal and Sudan. In those settings all types of FGM were found to pose an increased risk of death to the baby: 15 percent higher for Type I, 32 percent for Type II, and 55 percent for Type III.

Psychological complications include depression and loss of trust in caregivers. Toubia writes that girls living in communities where FGM is practised are torn between fear of the procedure and wanting to please their parents and gain social status. She writes that many infubulated women live with chronic anxiety and depression, and fear of infertility. Feelings of shame and betrayal can develop when they move outside their traditional circles and are confronted with the view that mutilation is not the norm. They typically report sexual dysfunction and dyspareunia (painful sexual intercourse), but FGM does not necessarily destroy sexual desire in women. According to several studies in the 1980s and 1990s, the women said they were able to enjoy sex, though with Type III the risk of sexual dysfunction was higher.

Prevalence

Further information: Prevalence of female genital mutilation by country

Prevalence of FGM in Africa

According to the WHO, 140 million women and girls are living with the effects of the practice, including 101 million girls over the age of ten in Africa, where it persists in 28 countries. Caldwell, Orubuloye and Caldwell write that 80–88 percent of women in Africa who have experienced FGM live in sub-Saharan Africa, 51 percent in West Africa and at least 27 percent in Nigeria. The WHO reports that nearly half live in Egypt and Ethiopia.

The practice is nearly universal in Djibouti, Egypt, Guinea and Somalia, and a majority of women have experienced it in Burkina Faso, Eritrea, Ethiopia, the Gambia, Liberia, Mali, Mauritania, Sierra Leone and Sudan. Around 85 percent of women who undergo it experience Types I and II, and 15 percent Type III. Type III is predominant in Djibouti, Somalia and Sudan, and in parts of Eritrea, Ethiopia and Mali.

Outside Africa, FGM occurs in Indonesia, Malaysia, among ethnic minorities in Iran, Iraq, Oman and Yemen, and among immigrant communities in Australia and New Zealand, Europe, the United States and Canada. UNICEF reported in 2013 that it is on the decline in Benin, the Central African Republic, Iraq, Kenya, Liberia, Nigeria and Tanzania.

Reasons for the practice

Overview

Further information: Religious views on female genital mutilation

Samburu FGM ceremony in Laikipia plateau, northern Kenya, 2005

FGM is viewed by its practitioners as an essential part of raising a girl. At the root of the practice is a desire to control women's sexuality, and to promote female chastity and sexual fidelity. Type III FGM encourages virginity and monogamy because of the pain associated with sex and the difficulty of undoing an infibulation without being discovered. In Egypt, Sudan and Somalia, the focus is on curbing premarital sex, whereas in Kenya and Uganda it is carried out to reduce a woman's sexual desire for her husband so that he can more easily take several wives. In both cases, Toubia argues, the aim is to serve the interests of male sexuality.

Aesthetically, female genitals are regarded by communities that practise FGM as dirty and ugly; physicians Miriam Martinelli and Jaume Enric Ollé-Goig write that the preference is for women's genitalia to be "flat, rigid and dry." There are also various myths that cite the clitoris as dangerous, able to poison a woman's breast milk if her baby touches it during birth, cause excess cranial fluid in babies, and harm a man if his penis touches it.

Among the many reasons for the practice's continuance is that the rituals surrounding FGM serve to reinforce ethnic boundaries and are seen as a joyful celebration of community values. A more practical reason is that the female circumcisers have no other way to earn a living, and as a result are highly motivated to uphold the view of FGM as a cultural necessity and matter of honour. Anti-FGM groups are therefore working with the circumcisers, training them in farming and other occupations.

While the likelihood of experiencing FGM increases with the Muslim population, it is not a religious requirement, and Islamic scholars debate whether it is desirable or even permitted. Mackie writes that it is not practised in Mecca or Medina, Islam's holiest cities, and is regarded as a pagan custom by the Saudis. Several Muslim leaders have spoken out against it, and a former mufti of Sudan issued a fatwa (religious ruling) against Type III. It has been practised in Christian and animist communities too, including by the Christian Copts in Egypt and Sudan. Judaism requires circumcision for boys, but does not allow it for girls. Shaye J. D. Cohen writes that the only Jews known to have practised FGM are the Beta Israel of Ethiopia.

Support from women

Urologist Jean Fourcroy writes that women in practising countries call it one of the "three feminine sorrows": the first the procedure itself, followed by the wedding night when a woman with Type III has to be cut open, then childbirth when she has to be cut again. Despite this, women themselves insist on the procedure for their daughters, or for themselves as adults, including before or after childbirth. Izett and Toubia write that pain and trauma are central to defining "appropriate female disposition and concepts of 'morally appropriate fertility,'" and that any change to the state of a woman's mutilation can affect her sense of identity and security. They cite the case of a Somali mother of three who was advised to remain defibulated after childbirth to cure her gonorrhoea, but who insisted on being re-infibulated, leading to pain and infection so severe she could hardly walk. They write that she did this out of "her own sense of impurity," not for her husband's benefit.

According to Toubia, a Sudanese surgeon and president of RAINBO (Research, Action and Information Network for the Bodily Integrity of Women), women with FGM may see themselves as "heightened to another level of pure motherhood – a motherhood not tainted by sexuality and that is why the woman gives it away to become the matron, respected by everyone." Boyle writes that the Masai Nilotes of Tanzania will not even call an uncircumcised woman "mother" when she has children. Because women see FGM as a way of moving from girlhood to womanhood, and of differentiating between each other, historian Lynn Thomas writes that to remove FGM is also to remove that opportunity to gain authority. Thus, argues Toubia, it is much harder to convince the women to give up FGM than it is the men. Feminist opponents of FGM have attributed the women's support for it to false consciousness, the idea that people oppressed by certain social relations may not see the exploitation inherent in them.

In some societies the procedure is performed to differentiate between the genders, based on the belief that the clitoris confers masculinity on a girl and the foreskin of a boy makes him feminine. Anthropologist Ellen Gruenbaum writes that in Sudan the clitoris and labia (the "masculine" parts) are viewed as ugly, and the smooth, infibulated vulva as feminine; a group of women asked another anthropologist, Janice Boddy: "Which is better, an ugly opening or a dignified closure?" Nearly 59 percent of 3,210 Sudanese women in a 1983 study said they preferred Types II and III, rather than the milder Type I.

History of opposition

Kenyan "female circumcision controversy"

Further information: Female circumcision controversy (Kenya, 1929–1932)

Map of Africa, 2005

Anika Rahman and Nahid Toubia write that attempts in the early 20th century by colonial administrators to halt FGM backfired. In Kenya, Christian missionaries in the 1920s and 1930s forbade their adherents from practising it – in part because of the medical consequences, but also because the accompanying rituals were seen as highly sexualized – and as a result it became a focal point of the independence movement among the Kikuyu, the country's main ethnic group. One American missionary, Hilda Stump, was murdered in January 1930 after speaking out against it.

Thomas writes that the 1929–1931 period became known in Kenyan historiography as the female circumcision controversy. Protestant missionaries campaigning against it tried to gain support from humanitarian and women's rights groups in London, where the issue was raised in the House of Commons, and in Kenya itself a person's stance toward FGM became a test of loyalty, either to the Christian churches or to the Kikuyu Central Association.

Support for the practice came from the women themselves. E. Mary Holding, a Methodist missionary in Meru, Kenya, wrote in 1942 that the ritual was an entirely female affair, organized by women's councils known as kiama gia ntonye ("the council of entering"). The procedure saw the girls become women, and allowed their mothers to become members of the women's council, a position of authority. Jomo Kenyatta (c. 1894–1978), who became Kenya's first prime minister in 1963, wrote in 1930 that in the tribal psychology of the Kikuyu the institution of FGM (the initiation ceremonies and the procedure itself) had "enormous educational, social, moral and religious implications."

In 1956, under pressure from the British, the council of male elders (the Njuri Nchecke) in Meru, Kenya, announced a ban on clitoridectomy. Over two thousand girls – mostly teenagers, but some as young as eight – were charged over the next three years with having carried out the procedure on each other with razor blades, a practice that came to be known as Ngaitana ("I will circumcise myself"), so-called because the girls claimed to have cut themselves to avoid naming their friends. Thomas describes the episode as significant in the history of FGM because it made clear that its apparent victims were in fact its perpetrators.

Development of opposition within Africa

Further information: Prevalence of female genital mutilation by country

The Egyptian Doctors' Society called in the late 1920s for FGM to be banned, and in December 1928 Ali Ibrahim Pasha, an Egyptian surgeon and director of Cairo University, spoke out against it during a medical conference. Opposition in Egypt continued throughout the 1930s to 1950s. A booklet published by Al Doktor in May 1951 criticized it as hazardous and unnecessary. An Egyptian women's magazine, Hawwaa, published a series of critical articles about it in 1957 and 1958, and the next year it became illegal to perform it in any of Egypt's state-run health facilities.

Nawal El Saadawi, the Egyptian feminist physician, spoke out against FGM in 1980.

In the 1960s and 1970s doctors in several African countries began to speak out about the effect of the practice on their patients, and opposition gathered pace during the United Nations Decade for Women (1975–1985). In October 1979 the Cairo Family Planning Association held a seminar, "Bodily Mutilation of Young Females," and a group of Egyptian legislators, theologians, physicians and social workers began to write pamphlets and hold meetings. Also in 1979 the American feminist writer Fran Hosken (1920–2006) presented her influential The Hosken Report: Genital and Sexual Mutilation of Females to the WHO's first "Seminar on Harmful Traditional Practices Affecting the Health of Women and Children." Rahman and Toubia write that African women from several countries led a vote to end the practice.

In 1980 Egyptian physician and feminist Nawal El Saadawi wrote about FGM as a dangerous practice intended to control women's sexuality, followed by similar arguments from Sudanese physician Asma El Dareer in her Woman, Why Do You Weep? (1982). Their work saw the framing of FGM in the 1980s as a human rights violation rather than a health concern, and this encouraged academic interest, including from feminist legal scholars.

In 1984 a group of African NGOs met in Dakar, Senegal, which led to the formation of the Inter-African Committee on Traditional Practices Affecting the Health of Women and Children, and in June 1993 the UN World Conference on Human Rights passed resolutions (the Vienna Declaration) recognizing the rights of women and girls, and opposing gender-based violence. After that several African countries enacted legislation against FGM, including Benin, Burkina Faso, the Central African Republic, Chad, Djibouti, Eritrea, Ethiopia, Ghana, Ivory Coast, Niger, Senegal, Tanzania, Togo and Uganda. President Daniel Moi of Kenya issued a decree against it in December 2001. In Mauritania 34 Islamic scholars signed a fatwa against it in January 2010.

After Egypt's 1959 ban on FGM in state-run hospitals, the practice continued elsewhere in the country, and in 1995 CNN broadcast images of a ten-year-old girl undergoing the procedure in a barber's shop in Cairo. As a result the government reversed its ban so that physicians could carry it out, but a domestic FGM Task Force was set up to persuade the government that medicalizing the procedure simply added physicians to the list of perpetrators. The government restored the ban in 2007 after the death of 12-year-old Badour Shaker, who died of an overdose of anaesthesia during or after an FGM procedure for which her mother had paid a physician in an illegal clinic the equivalent of $9.00. The Al-Azhar Supreme Council of Islamic Research, the highest religious authority in Egypt, issued a statement that FGM had no basis in core Islamic law, and this enabled the government to outlaw it entirely.

Opposition in non-practising countries

Further information: Prevalence of female genital mutilation by country § Legal status in other regions, and Tahirih Justice Center

Since 2003 the United Nations has sponsored an annual International Day of Zero Tolerance to Female Genital Mutilation every 6 February, and in December 2012 the UN General Assembly voted unanimously to ban the practice.

As a result of immigration, FGM spread to Australia, Canada, Europe (particularly France and the UK, because of immigration from former colonies), New Zealand, Scandinavia and the United States. Families who have immigrated from practising countries may send their daughters there to undergo FGM, ostensibly to visit a relative, or fly in circumcisers to conduct the procedure in people's homes. Sweden passed legislation in 1982, the first country to do so. It is outlawed in Australia and New Zealand, across the European Union, and under section 268 of the Criminal Code of Canada. Canada was the first to recognize FGM as a form of persecution when it granted refugee status in 1994 to Khadra Hassan Farah, who fled Somalia with her 10-year-old daughter to avoid the girl being subjected to it. As of May 2012 there had been no prosecutions in Canada.

There have been prosecutions in Europe, particularly in France, where FGM is covered by a provision of the penal code punishing acts of violence against children that result in mutilation or disability. There are thought to be up to 30,000 women in France who have experienced FGM, and thousands of girls at risk. Colette Gallard, a French family planning counsellor, writes that when it was first encountered there, the initial reaction was that Westerners ought not to intervene, and it took the deaths of two girls in 1982, one of them three months old, for that attitude to change. Between then and 2012 there were 40 trials, resulting in convictions against two practitioners and over 100 parents. There have been no prosecutions in the United Kingdom, where as of 2001 nearly 66,000 women were living with FGM and 21,000 girls were at risk. The Prohibition of Female Circumcision Act 1985 outlawed the procedure domestically, and the Female Genital Mutilation Act 2003 and Prohibition of Female Genital Mutilation (Scotland) Act 2005 made it an offence to arrange to have it performed outside the UK on British citizens or permanent residents. In June 2013 the British National Society for the Prevention of Cruelty to Children launched a 24-hour national helpline (0800 028 3550) that children at risk can call.

In the United States, the Centers for Disease Control estimated in 1997 that 168,000 girls living there had undergone FGM or were at risk. Fauziya Kasinga, a 19-year-old woman from Togo and member of the Tchamba-Kunsuntu ethnic group, was granted asylum in 1996 after leaving an arranged marriage to escape FGM, setting a precedent in US immigration law. Performing FGM on anyone under the age of 18 became illegal the following year with the Federal Prohibition of Female Genital Mutilation Act, and 17 states enacted similar legislation between 1994 and 2006. The Transport for Female Genital Mutilation Act was passed in January 2013 and prohibits knowingly transporting a girl out of the country for the purpose of undergoing FGM. Khalid Adem, who emigrated from Ethiopia to Atlanta, Georgia, became the first person in the US to be convicted in an FGM case; he was sentenced to ten years in 2006 for having severed his two-year-old daughter's clitoris with a pair of scissors.

Criticism of the Western opposition

Some of the opposition to FGM has attracted criticism. Ugandan law professor Sylvia Tamale argues that the early Western opposition stemmed from a Judeo-Christian, voyeuristic judgment that African sexual culture, including FGM, dry sex, polygyny and levirate marriage, consisted of primitive practices that required correction. Fran Hosken's The Hosken Report: Genital and Sexual Mutilation of Females (1979), in particular, was criticized for alleged ethnocentrism and its insistence on Western intervention. Hosken was uncompromising in her language. She called FGM a "training ground for male violence," saw the women as "mentally castrated" and "participating in the destruction of their own kind," and argued that infibulation "teaches male children that the most extreme forms of torture and brutality against women and girls is their absolute right and what is expected of real men."

Tamale writes that, following the report's publication, opposition to FGM became an obsession of Western anthropologists and women's rights activists, who "flocked to the continent with the zeal of missionaries to save African women from this barbaric practice." While African research also opposes FGM, she cautions that African feminists continue to object to what she calls the "imperialist, racist and dehumanising infantilization of African women" inherent in some of the attempts to stem it.

Historian Chima Korieh argues that Western feminists and agencies approach FGM as if it were a plague. Lacking knowledge of non-Western approaches to gender and sexuality, they ignore the roles and interests of the women who support it, objectifying African women and presenting them as "mutilated, abject bodies." He offers as an example a series of photographs of an FGM ceremony in Kenya, taken by an American female photographer, that won the 1996 Pulitzer Prize for Feature Photography. The 16-year-old girl being cut did not give her consent to be photographed, yet images of her naked body were published by 12 American newspapers.

Gynaecologist Birgitta Essén and anthropologist Sara Johnsdotter describe the Western feminist view of African women as one that sees the women as perpetual victims, prisoners of ritual (as Hanny Lightfoot-Klein called them) rather than decision-makers. The view has led to a zero tolerance approach to FGM, they write, so that even the symbolism of the practice is now rejected. The Dutch government had to withdraw a proposal in 1992 that doctors be allowed to perform ritual pricking of the clitoral hood, to satisfy parents who had emigrated from practising countries, after protests that it would fall foul of the WHO's definition of Type IV FGM, which includes pricking. The chair of the Inter-African Committee on Traditional Practices in Addis Ababa argued in response to the proposal that any FGM symbolism "reconfirm[s] the subjugation of women."

Comparison with cosmetic procedures

The WHO does not include cosmetic procedures such as labiaplasty (reduction of the inner labia), vaginoplasty (tightening of the vaginal muscles) and clitoral hood reduction as examples of FGM. The group writes that some elective practices do fall into their categories, but its broad definition aims to avoid loopholes. Essén and Johnsdotter argue that this is a double standard, with adult African women (for example, those seeking reinfibulation after childbirth) viewed as mutilators trapped in a primitive culture, while other women seeking cosmetic genital surgery are exercising their right to control their own bodies.

Demand for cosmetic genital alteration is increasing in the West as young women are exposed to more nudity, particularly pornography, and as the fashion for pubic-hair removal reveals the wide difference in genital appearance. The health risks of the procedures include infection, scarring, tissue adhesions, and nerve damage leading to dyspareunia (painful sexual intercourse) or loss of sensation. While there are important distinctions between FGM and cosmetic procedures – not least of which is that the latter take place in medical facilities between consenting adults – Essén and Johnsdotter write that some physicians have drawn a parallel, and that Western women choosing cosmetic alteration can be victims of patriarchy and false consciousness just as much as women in Africa. Ronán Conroy of the Royal College of Surgeons in Ireland referred to cosmetic genital procedures in 2006 as the "latest chapter in the surgical victimisation of women ... driving the advance of female genital mutilation by promoting the fear in women that what is natural biological variation is a ... problem requiring the knife."

Some of the legislation banning FGM would seem to cover cosmetic genital alteration. The law in Sweden, for example, bans operations "on the external female genital organs which are designed to mutilate them or produce other permanent changes in them ... regardless of whether consent ... has or has not been given." In the UK the Female Genital Mutilation Act 2003 says: "A person is guilty of an offence if he excises, infibulates or otherwise mutilates the whole or any part of a girl's labia majora, labia minora or clitoris," unless "necessary for her physical or mental health." Although the legislation refers to girls, it applies to women too.

Because anti-FGM laws are not used to stop cosmetic genital procedures, Essén and Johnsdotter argue that it seems the law distinguishes between Western and African female genitals, and deems only African women unfit to make their own decisions. Where FGM is banned even if consent is given, physicians may end up having to ask of prospective patients whether they appear to be victims of African patriarchy before deciding whether to offer them genital alteration. Essén and Johnsdotter write that, if the aim of the legislation is to protect children, it ought to allow all adult women, regardless of ethnicity, the same right to make decisions about their own genitals. Alternatively, the health risks of FGM and cosmetic genital modification ought to be examined equally so that women seeking the procedures can be challenged on those grounds alone, without reference to ethnicity.

Notes

Sources are listed in long form on first reference and short form thereafter.

References

Books and papers are listed in the Notes section and repeated below; agency reports, websites and news reports are in the Notes section only.

• Abdalla, Raqiya Haji Dualeh. Sisters in Affliction: Circumcision and Infibulation of Women in Africa Women in the Third World, Zed Books, 1982.
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• Abdulcadira, Jasmine; Margairaz, C.; Boulvain, M; Irion, O. "Care of women with female genital mutilation/cutting", Swiss Medical Weekly, 6(14), January 2011.
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• Abusharaf, Rogaia Mustafa. "Revisiting Feminist Discourses on Inbulation: The Hosken Report," in Bettina Shell-Duncan and Ylva Hernlund (eds.), Female "Circumcision" in Africa, Lynne Rienner Publishers, 2000.
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• Bergrren, Vanja et al. "An explorative study of Sudanese midwives’ motives, perceptions and experiences of re-infibulation after birth", Midwifery, 20(4), December 2004, pp. 299–311.
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• Boddy, Janice. Wombs and Alien Spirits: Women, Men, and the Zar Cult in Northern Sudan, University of Wisconsin Press, 1989.
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• Hosken, Fran. The Hosken Report: Genital and Sexual Mutilation of Females, Women's International Network, 1979.
• Izett, Susan and Toubia, Nahid. "Female Genital Mutilation: An Overview", World Health Organization, 1998.
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• Johnsdotter, Sara and Essén, Birgitta. "Genitals and ethnicity: the politics of genital modifications", Reproductive Health Matters, 18(35), 2010, pp. 29–37.
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• Toubia, Nahid. "Female Circumcision as a Public Health Issue", The New England Journal of Medicine, 331(11), 1994, pp. 712–716.
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Further reading

Resources

• End FGM campaign, End FGM European campaign run by Amnesty International.
• FORWARD, The Foundation for Women's Health, Research and Development.
• "Hospitals and Clinics in the UK offering Specialist FGM (Female Genital Mutilation) Services", FORWARD.
• "First female genital mutilation clinic opens", The Local, 10 September 2013 (Europe's first dedicated clinic, The Desert Flower Centre, opens in Berlin).

Books

• Abdalla, Raqiya Haji Dualeh. Sisters in Affliction: Circumcision and Infibulation of Women in Africa, Zed Books, 1982.
• Aldeeb, Sami. Male & Female circumcision: Among Jews, Christians and Muslims, Shangri-La Publications, 2001.
• Dettwyler, Katherine A. Dancing Skeletons: Life and Death in West Africa, Waveland Press, 1994.
• Ehrenreich, Barbara and English, Deirdre. Complaints and Disorders: The Sexual Politics of Sickness, The Feminist Press at CUNY.
• Mernissi, Fatima. Beyond the Veil: Male-Female Dynamics in a Modern Muslim Society, Indiana University Press, 1987, first published 1975.
• Population Council Jakarta. "Female Circumcision in Indonesia", September 2003.
• Sanderson, Lilian Passmore. Against the Mutilation of Women, Ithaca Press, 1981.
• Skaine, Rosemarie. Female Genital Mutilation, McFarland & Company, 2005.
• Toubia, Nahid. Female Genital Mutilation: A Call for Global Action, Women's Ink, 1993.
• Toubia, Nahid. Caring for Women with Circumcision: A Technical Manual for Health Care Providers, Research Action & Information, 1999.
• Walker, Alice. Possessing the Secret of Joy, New Press, 1993 (novel).
• Zabus, Chantal. Between Rites and Rights: Excision on Trial in African Women's Texts and Human Contexts, Stanford University Press, 2007.

Personal stories

• Ali, Ayaan Hirsi. Infidel: My Life, Simon & Schuster, 2007: Ali experiences FGM at the hands of her grandmother.
• Dirie, Waris. Desert Flower, Harper Perennial, 1999: autobiographical novel about Dirie's childhood and genital mutilation.
• Dirie, Waris. Desert Dawn, Little, Brown, 2003: how Dirie became a UN Special Ambassador for FGM.
• Dirie, Waris. Desert Children, Virago, 2007: FGM in Europe.
• Kasinga, Fauziya, and Bashir, Layli Miller. Do They Hear You When You Cry, Delacorte Press, 1998.
• El Saadawi, Nawal. Woman at Point Zero, Zed Books, 1975.
• Williams-Garcia, Rita. No Laughter Here, HarperCollins, 2004: a ten-year-old Nigerian girl undergoes FGM while on vacation in her homeland.

Articles

• Abusharaf, Rogaia Mustafa. "Virtuous Cuts: Female Genital Circumcision in an African Ontology", Differences: A Journal of Feminist Cultural Studies, 12, 2001, pp. 112–140.
• Althaus, Francis A. "Female Circumcision: Rite of Passage Or Violation of Rights?", International Family Planning Perspectives, 23(3), September 1997.
• Boddy, Janice. "Womb as oasis: The symbolic context of Pharaonic circumcision in rural Northerm Sudan", American Ethnologist, 9(4), November 1982.
• Chase, Cheryl. "'Cultural practice' or 'Reconstructive Surgery'? U.S. Genital Cutting, the Intersex Movement, and Medical Double Standards", in Stanlie M. James and Claire C. Robertson (eds.). Genital Cutting and Transnational Sisterhood. University of Illinois Press, 2002.
• Darugar, Maliha A; Harris, Rebecca M; and Frader, Joel E. "Consent and cultural conflicts: ethical issues in pediatric anesthesiologists' participation in female genital cutting", in Gail A. Van Norman et al. Clinical Ethics in Anesthesiology: A Case-Based Textbook. Cambridge University Press, 2010.
• Ehrenreich, Nancy and Barr, Mark. "Intersex Surgery, Female Genital Cutting, and the Selective Condemnation of 'Cultural Practices'", Harvard Civil Rights-Civil Liberties Law Review, 40(1), 2005, pp. 71–140.
• Ferguson, Ian and Ellis, Pamela. "Female Genital Mutilation: a Review of the Current Literature", Research Section, Department of Justice, Canada, 1995.
• Haworth, Abigail. "The day I saw 248 girls suffering genital mutilation", The Guardian, 18 November 2012.
• Kouba, Leonard and Muascher, Judith. "Female Circumcision in Africa: An Overview", African Studies Review, 28(1), March 1985, pp. 95–110.
• Mustafa, Asim Zaki. "Female circumcision and infibulation in the Sudan", Journal of Obstetrics and Gynaecology, 73(2), 1966, pp. 302–306.
• Oguntoye, Susana. "'FGM is with us Everyday': Women and Girls Speak Out about Female Genital Mutilation in the UK", World Academy of Science and Engineering, 54, 2009.
• Population Reference Bureau. "Female Genital Mutilation/Cutting: Data and Trends", 2008.
• Shell-Duncan, Bettina. "The medicalization of female "circumcision": harm reduction or promotion of a dangerous practice?, Social Science & Medicine, 52(7), 2001, pp. 1013–1028.
• UNICEF. "Coordinated Strategy to Abandon Female Genital Mutilation/Cutting in One Generation", undated.
• UNICEF. [http://www.unicef.org/publications/files/FGM-C_final_10_October.pdf "Female Genital Mutilation/Cutting: A statistical exploration", 2005.
• Westley, David M. "Female circumcision and infibulation in Africa", Electronic Journal of Africana Bibliography, 4, 1999 (contains an extensive bibliography).

Films

• Brendecke, Dagmar and Müller-Belecke, Anke. Schnitt ins Leben – Afrikanerinnen bekämpfen ein Ritual, Germany, 2000 (documentary).
• Dacosse, Marc and Eric Dagostino, Eric. L’Appel de Diégoune (Walking the Path of Unity), Tostan, France, 2009.
• Eran, Doron. God's Sandbox, Israel, 2006 (an Israeli girl joins a Bedouin tribe and is forced to undergo FGM).
• Hormann, Sherry. Desert Flower, 2009 (based on Waris Dirie's book, Desert Flower).
• Johnson, Kirsten and Pimsleur, Julia, Bintou in Paris, France, 1995 (documentary).
• Kouros, Alex. Kokonainen, Finland, 2005 (won the 2005 New York Short Film Festival Jury Award for Best Screenplay).
• Longinotto, Kim. The Day I Will Never Forget, UK, 2002.
• Maldonado, Fabiola. Maimouna – La vie devant moi, Germany, 2007 (documentary).
• Pomerance, Erica. Dabla! Excision, Canada, 2003 (follows the growing movement across Africa to stop FGM).
• Sembène, Ousmane. Moolaadé, Senegal, France, Burkina Faso, Cameroon, Morocco, Tunisia, 2004.
• Sissoko, Cheick Oumar. Finzan, Mali, 1989 (two women rebel against the traditions of a village society).
• Van Zeller, Mariana. "Female Genital Cutting," Vanguard, Current TV, 31 January 2007.
• Wilkins, Oliver. Short film on FGM in Minya, Egypt, vimeo.com.